Reviewer: V. Dimov, M.D.
A 37-year-old female with unremarkable past medical history was admitted with sudden onset of dizziness, aphasia, and right arm numbness and weakness. The patient's symptoms lasted approximately 45 minutes and then slowly resolved after which she was able to call for help. A few hours before the onset of her symptoms, she had her "usual" neck stiffness and thus she went to a chiropractor. She had a neck manipulation which alleviated the pain.
Past medical history (PMH)
On physical examination, the blood pressure was 148/95 mm Hg and the patient was afebrile. Neurologic examination was nonfocal. Right arm numbness was still present.
What tests would you suggest?
MRI of the brain showed 4 tiny foci suggestive of multifocal acute to subacute ischemic changes in the left parietal lobe. MRA of the head and neck showed bilateral internal carotid artery dissection and markedly diminished intracranial flow throughout the left middle cerebral artery distribution. There was no evidence of dysplasia on MRA. The vertebral arteries were widely patent and within normal limits.
What treatment would you suggest?
The patient was started on heparin infusion and bridged to warfarin.
What tests would you do next?
Hypercoagulability workup including antiphospholipid antibody was negative. ESR and CRP were normal. Echocardiogram did not reveal any abnormalities.
The patient's symptoms completely resolved and she was discharged home in a stable condition on warfarin with a target INR 2-3.
Bilateral internal carotid artery dissection with ischemic changes in the left parietal lobe due to chiropractic neck manipulation.
What did we learn from this case?
While neurological manifestations following chiropractic neck manipulation have been attributed to vertebral artery dissection and subsequent vertebrobasilar ischemia; injuries to the internal carotids arteries following spine manipulation are rarely reported. We report a patient with bilateral ICA dissection after visiting chiropractor for neck relief. Our patient did not have known risk factors for artery dissections, including but not limited to, fibromuscular dysplasia, Marfan syndrome, Ehlers-Danlos syndrome, oral contraception, or arteriosclerosis, but did admit to history of gestational hypertension and blood pressure was elevated on presentation.
Neurological deficits after spine manipulation vary widely in timing and presentation. The dissection is thought to occur due to shear force on the wall of the vessel. Symptoms may occur within minutes or weeks. Clinical manifestations depend on the affected cerebral circulation. While our patient exhibited word-finding difficulty and right hand numbness, which are suggestive of middle cerebral artery distribution, patients with vertebral artery involvement may present with occipital headache, neck pain, nausea, vomiting, or tinnitus. These symptoms may be transient thus making increased awareness a priority, as such patients should not be subjected to additional cervical spine manipulation. The majority of infarcts related to ICA dissection are cortical or subcortical and commonly caused by embolic phenomenon. This is in contrast to infarcts that involve the watershed or junctional areas where hemodynamic compromise plays a role.
Serious and sometimes fatal neurological complications may occur following cervical spine manipulation. Transient neurological symptoms may be the first manifestations. Hospitalists must be vigilant of these complications as early recognition may prevent death.
Catastrophic complication of chiropractic manipulation: a report of quadriparesis. Talluri SK, Talluri J, Besur S, Kakarala R, Klair N. Am J Med. 2009 Nov;122(11):e3-4.